AGREEMENT WITH
Exhibit 10.9
THREE RIVERS PROVIDER NETWORK
AGREEMENT WITH
______________________________
This Agreement is made this 23rd day of October 2008, by and between Three Rivers Provider Network, Inc., a Nevada Corporation (“TRPN”) and Fort Bend SA Services a Provider Group of health care services. TRPN contracts with hospitals, physicians, ancillaries and entities hereinafter referred to as “Provider” rendering medical and health care services at pre-determined rates as follow.
1. Clients. Covered Services. Contract Rates: TRPN contracts with insurance companies, third party administrators, health plans, individuals and entities hereinafter referred to as “Clients” that directly or indirectly access TRPN contracted providers for covered services. Covered Services shall include all services that are medically necessary including health, workers’ compensation, automobile and general liability. The rate used in conjunction with this Agreement will be a * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles. Clients are obligated to make payment directly to provider only at the contracted rate as payment in full. Provider shall not balance xxxx the patient upon receipt of payment in full at the contracted rate. TRPN has no responsibility to make payments on behalf of Clients. Payments shall be made within thirty (30) calendar days of receipt of clean claim. Where a state mandated fee schedule exists, provider agrees to accept a * discount below the state schedule. Payments made and cashed by the provider shall be accepted as payment in full and fulfillment of all terms of the agreement, providing the total payment including the member’s portion is not less than the contracted rate.
2. Licenses, Standards of Care: Provider agrees to deliver health care services that meet all legal standards of care complying with applicable Federal, State and Local laws and maintains the standards of NCQA and/or JCAHO. The provider is delegated by TRPN to carry out and/or assign credentialing responsibilities. Evidence of such licenses, certificates and standards shall be made available to TRPN upon request.
3. Term and Termination: This Agreement shall continue in effect for a period of one (1) years with automatic successive one (1) year terms. This Agreement may be terminated by either party without cause with a ninety (90) day prior written notice to the other party at the mailing addresses listed under the signatures. This Agreement may be immediately terminated with cause by TRPN should Provider lose applicable licenses, malpractice coverage, fail to honor the applicable contracted rates pursuant to this Agreement, or if any information provided in Attachment A is illegible, incomplete, or invalid.
4. Dispute Resolution: This Agreement shall be construed and interpreted in accordance with the laws of the State of Nevada. Provider agrees to meet and confer in good faith to resolve any disputes that may arise under this Agreement. If a dispute between TRPN and Provider arises out of this Agreement and is not resolved, either party may submit the dispute to arbitration which shall be commenced and conducted in accordance with the Rules of Practice and Procedures of the Judicial Arbitration and Mediation Services, Inc. (“JAMS”) as in effect at the time (“JAMS Rules”).
5. Attachment A: All information provided in Attachment A of this Agreement is complete and accurate to the best of Provider’s knowledge and Provider shall immediately notify TRPN of any changes thereto. Provider agrees to xxxx “N/A” next to any blank that is not applicable to Provider’s business.
6. Faxed Signatures: The parties agree that facsimile signatures of authorized representatives of the parties shall legally bind the parties to the terms and conditions of this Agreement as if the signatures were original and shall be considered evidence of a fully executed Agreement.
*
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Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act. Confidential portions of this document have been filed separately with the Securities and Exchange Commission.
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Page 1
IN WITNESS WHEREOF, the authorized parties hereto have executed this Agreement and intend to be bound thereby.
PROVIDER GROUP NAME (Please Print): | ATTENTION:XXXX XXXXXXXX | |
TRPN CONTRACTING COORDINATOR | ||
THREE RIVERS PROVIDER NETWORK | ||
Signature: /s/ Xxxxx Xxxx | Signature: | |
Title: COO | ||
Date: 10/23/08 | ||
NAME: Xxxx Xxxxxxx, C.O.O. | ||
Mailing Address: 0000 Xxxxx Xxxxxx Xxxxx 000 | ||
Xxx Xxxxx, XX 00000 Phone: (000) 000-0000 | ||
Date: |
ATTACHMENT A: PROVIDER INFORMATION
(Please attach a roster of all the provider’s full names, titles, NPI#s, and all locations under the group’s Tax Id#, use Addendum A)
Tax ID: 00-0000000 | Practice Name: Fort Bend SA Services |
National Provider Identifier (NPI): | |
126569033 | Group / IPA Affiliation:___________ |
(If there is more than one NPI Number, please attach a listing.)
|
|
Degree: LSA, CSA,SA-C, CST/CFA, CRNFA, RN, CNOR | Office Hours: 8-4:30 |
Specialty : Surgical Assisting | |
First Assist | Primary Address: X.X. Xxx 000 |
Xxxxx XX 00000 | |
County: Xxxxxx | |
Phone: 000-000-0000 Fax: 000-000-0000 | |
Email: Xxxxxxxxx@xx.xxx | |
Other Practice and/or Billing Address: Yes □ No □ | |
If “yes”, attach page with additional information | |
Hospital Affiliations (list name, date and type): | |
See Attachment. | |
Provider agrees to xxxx “N/A” next to any blank that is not applicable to Provider’s business.
Page 2
ADDENDUM A:
MEDICAL STAFF LISTING & FACILITY LOCATIONS
_______________________________
i. | The attached roster of providers and or locations will be participating under this Agreement between Fort Bend SA Services and Three Rivers Provider Network and shall include Tax Identification Numbers, NPI Numbers, Address(s), Phone and Fax Numbers. |
Page 3
FORT BEND SA SERVICES
|
Bayshore Medical Center
0000 Xxxxxxx Xxxxxxx
Xxxxxxxx XX 00000
|
Christus St. Catherine’s
000 Xxxxx Xxx Xxxx
Xxxx XX 00000
|
Christus St. Xxxx Hospital
00000 Xx. Xxxx Xx.
Xxxxxx Xxx, XX 00000
|
Clear Lake Medical Center
000 Xxxxxx Xxxxxx Xxxx.
Xxxxxxx XX 00000
|
Cypress Fairbanks Medical Center
00000 Xxxxxxxxxx Xxxxx
Xxxxxxx, XX 00000
|
Doctors Surgical Center
0000 Xxxxxxxxx Xxxxxxx
Xxxxxxx XX 00000
|
East Houston Regional Medical Center
00000 Xxxx Xxxxxxx
Xxxxxxx XX 00000
|
East Side Surgery Center
00000 Xxxx Xxxxxxx
Xxxxxxx XX 00000
|
First Street Hospital
0000 Xxxxxxxxx
Xxxxxxxx XX 00000
|
First Surgical Memorial Village
00000 Xxxxxxxx Xxxx #000
Xxxxxxx XX 00000
|
First Surgical Partners LLC
000 Xxxxx Xxxxxx
Xxxxxxxx XX 00000
|
Foundations Surgery Center
0000 Xxxx Xxxx Xxxxx
Xxxxxxxx XX 00000
|
Houston NW Medical Center
000 XX 0000 Xxxx
Xxxxxxx, XX 00000
|
Katy St. Catherine’s Surgery Center
000 Xxxxx Xxx Xxxx #000
Xxxx XX 00000
|
FORT BEND SA SERVICES
|
Kingwood Medical Center
00000 XX Xxxxxxx 00
Xxxxxxxx XX 00000
|
Memorial Hermann
0000 Xxxxxx
Xxxxxxx, XX 00000
|
Memorial Hermann Memorial City
000 Xxxxxxx Xxxx
Xxxxxxx XX 00000
|
Memorial Hermann Northwest
0000 Xxxxx Xxxx Xxxx
Xxxxxxx XX 00000
|
Memorial Hermann Southeast
00000 Xxxxxxx Xxxx
Xxxxxxx XX 00000
|
Memorial Hermann Southwest
0000 Xxxxxxxx
Xxxxxxx XX 00000
|
Memorial Hermann Surgery Center Northwest
0000 Xxxxx Xxxx Xxxx #000
Xxxxxxx XX 00000
|
Memorial Hermann Surgery Center Southwest
0000 Xxxxxxxxx Xxxxxxx #000
Xxxxxxx XX 00000
|
Memorial Hermann The Woodlands
0000 Xxxxxxxxx
Xxx Xxxxxxxxx XX 00000
|
Methodist Sugar Land
00000 Xxxxxxxxx Xxxxxxx
Xxxxx Xxxx XX 00000
|
Methodist Willowbrook
00000 Xxxxxxx Xxxxxxx
Xxxxxxx XX 00000
|
North Cypress Medical Center
00000 Xxxxxxxxx Xxxxxxx
Xxxxxxx XX 00000
|
Northeast Medical Center
00000 Xxxxxxxx Xxxxx
Xxxxxx XX 00000
|
OakBend Medical Center
0000 Xxxxxxx Xxxxxx
Xxxxxxxx XX 00000
|
FORT BEND SA SERVICES
|
Palladium Surgery Center
0000 Xxxxxxxxx Xxxxxxx #000
Xxxxxxx XX 00000
|
Park Plaza Hospital
0000 Xxxxxxx Xxxxx
Xxxxxxx XX 00000
|
Special Surgery Centre
0000 Xxxx Xxxxxxx Xxxxx 000
Xxxxxxx XX 00000
|
Spring Branch Medical Center
0000 Xxxx Xxxxx
Xxxxxxx XX 00000
|
St. Xxxxxx Medical Center
0000 Xx. Xxxxxx Xxxxxxx
Xxxxxxx, XX 00000
|
St. Luke’s Episcopal Hospital Sugar Land
0000 Xxxx Xxxxx Xxxxxxx
Xxxxx Xxxx XX 00000
|
St. Luke’s Episcopal Hospital
0000 Xxxxxxx Xxxxxx
Xxxxxxx XX 00000
|
Sugar Land Surgical Hospital
0000 Xxxxxxx 0 Xxxxx 00
Xxxxx Xxxx XX 00000
|
The Woman’s Hospital
0000 Xxxxxx
Xxxxxxx XX 00000
|
West Houston Medical Center
00000 Xxxxxxxx Xxxxxx
Xxxxxxx XX 00000
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West Houston Surgicare
000 Xxxxxxxx Xxxx
Xxxxxxx XX 00000
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Provider List
10/23/2008
Code | Name | National Provider Identifier | Credentials | License Number |
Last Name | ||||
XX
XXXXXX
|
XXXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00024
|
SA
XXXX
|
XXXX, SAYED
|
0000000000
|
LSA
|
SA00289
|
XX
XXXXXXX
|
XXXXXXX, XXXX
|
0000000000
|
LSA
|
SA00283
|
OA
AKUPUE
|
AKUPUE, OKECHUKWU
|
0000000000
|
LSA
|
SA00307
|
MA
XX XXXX
|
XX XXXX, MOHD
|
0000000000
|
LSA
|
SA00309
|
XX
XXXXXX
|
XXXXXX, RECTO
|
0000000000
|
SA-C
|
A01143
|
AA
ARREOZOLA
|
XXXXXXXXX, XXXXXXXXX
|
0000000000
|
LSA
|
SA00299
|
XX
XXXXXX
|
XXXXXX, XXXXX
|
0000000000
|
LSA
|
A03119
|
MA01
XXXXXX
|
XXXXXX, XXXX
|
0000000000
|
LSA
|
SA00029
|
IA
XXXX
|
XXXX, ILIA
|
0000000000
|
CSA
|
CSA04209
|
QB
BABURI
|
BABURI, QASIM
|
0000000000
|
LSA
|
SA00160
|
VB01
BARCES
|
XXXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00161
|
XX
XXXXXX`
|
XXXXXX, XXXXXXXXX
|
0000000000
|
LSA
|
SA00290
|
XX
XXXXXXX
|
XXXXXXX, XXXXXX
|
0000000000
|
LSA
|
SA00163
|
XX
XXXXX
|
XXXXX, XXXXXXX
|
0000000000
|
CST/CFA
|
109540
|
1
Provider List
10/23/2008
Code | Name | National Provider Identifier | Credentials | License Number |
Last Name | ||||
DGB
XXXXXX
|
XXXXXX, XXXXX G
|
0000000000
|
LSA
|
SA00291
|
XX
XXXXXXXXX
|
XXXXXXXXX, XXXXXX
|
0000000000
|
XXX
|
XX00000
|
JC01
CANSECO
|
XXXXXXX, XXXX
|
0000000000
|
LSA
|
SA00110
|
JC002
XXXXXXX
|
XXXXXXX, XXXX
|
0000000000
|
XX-X
|
00000
|
XX
XXXXXX
|
XXXXXX, XXXXX
|
0000000000
|
CSA
|
|
XX XXXXXXXXXXX
|
XXXXXXXXXXX, XXXXX
|
0000000000
|
LSA
|
SA00237
|
XX
XXXXX
|
XXXXX, XXXX
|
0000000000
|
LSA
|
SA00255
|
XX
XXXXXXXX
|
XXXXXXXX, XXXXXXXX
|
0000000000
|
LSA
|
SA00277
|
MC01
XXXXXXX
|
XXXXXXX, XXXX
|
0000000000
|
SA-C
|
07272
|
XX
XXXX
|
XXXX, VIRGINIA
|
0000000000
|
CSA
|
A05223
|
AD
DARWISHS-SALAMA
|
DARWISHS-XXXXXX,
XXXXXXX
|
0000000000
|
XXX
|
XX0000
|
ND
XXXXX
|
XXXXX, XXXXXX
|
0000000000
|
CSA
|
ABSA 001163
|
BE
XXXXX
|
XXXXX, XXXXX
|
0000000000
|
CRNFA
|
061022
|
XX
XXXXXXX
|
ELGAMAL, ZAK
|
0000000000
|
LSA
|
SA00011
|
XX
XXXXX
|
XXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00038
|
2
Provider List
10/23/2008
Code | Name | National Provider Identifier | Credentials | License Number |
Last Name | ||||
XX
XXXXXX
|
XXXXXX, XXXXX
|
0000000000
|
LSA
|
SA00069
|
XX
XXXXXX
|
XXXXXX, XXXXXXX
|
0000000000
|
CNOR
|
CNOR030775
|
XX
XXXXX
|
XXXXX, XXXX
|
0000000000
|
LSA
|
SA00170
|
XX
XXXXXX
|
XXXXXX, XXXX
|
0000000000
|
LSA
|
SA00073
|
XX
XXXXXX-XXXXXXX
|
XXXXXX-XXXXXXX, XXXXXX
|
0000000000
|
XXX
|
XX0000
|
EG
XXXXXX
|
XXXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00270
|
XX
XXXXXXXX
|
XXXXXXXX, XXXX
|
0000000000
|
CSA
|
A06115
|
XX
XXXXXXXX
|
XXXXXXXX, XXXX
|
0000000000
|
SA-C
|
07336
|
XX
XXXXXXXXX
|
XXXXXXXXX, XXXX
|
0000000000
|
CSA
|
SA2582
|
XX
XXXXXX
|
XXXXXX, XXXXXX
|
0000000000
|
CSA
|
CSA2667
|
XX
XXXX
|
KHAN, SOSUN
|
0000000000
|
LSA
|
SA00272
|
XX
XXXX
|
XXXX, XXXXXXX
|
0000000000
|
SA-C
|
A03118
|
XX
XXXXX
|
XXXXX, XXXXX
|
0000000000
|
CSA
|
A05224
|
JM0-1
XXXXXXX
|
XXXXXXX, XXXXXXX
|
0000000000
|
CSA
|
CSA3044
|
XX
XXXXXXX
|
XXXXXXX, XXXX
|
0000000000
|
LSA
|
SA00129
|
3
Provider List
10/23/2008
Code | Name | National Provider Identifier | Credentials | License Number |
Last Name | ||||
XX
XXXXXXX
|
XXXXXXX, XXXXXX
|
0000000000
|
LSA
|
SA00263
|
XX
XXXXXXXX
|
XXXXXXXX, OMAR
|
0000000000
|
LSA
|
SA00286
|
MM
MAYOR
|
MAYOR, MASOUDA
|
0000000000
|
LSA
|
SA00296
|
XX
XXXXXX
|
XXXXXX, XXXXXX
|
0000000000
|
SAC
|
03132
|
XX
XXXXX
|
XXXXX, XXXX
|
1154440983
|
CSA
|
A06119
|
XX
XXXXXXXXX
|
XXXXXXXXX, XXXXXXXX
|
0000000000
|
LSA
|
SA00084
|
NN
XXXXXX
|
XXXXXX, NAYEF
|
0000000000
|
LSA
|
SA00135
|
XX
XXXXX
|
NESIC, J-XXXXXX
|
0000000000
|
LSA
|
SA00312
|
CN
NNA-WOSU
|
NNA-WOSU, CHI
|
0000000000
|
LSA
|
SA00085
|
XXX
XXXX
|
XXXX, XXXXX X
|
0000000000
|
XXX
|
XX00000
|
HP
XXXXXXXX
|
XXXXXXXX, XXXXX
|
0000000000
|
CSA
|
A05207
|
XX
XXXXXX
|
XXXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00020
|
KP01
XXXXX
|
XXXXX, XXXXX
|
0000000000
|
SA-C
|
A05217
|
LP01
XXXXXXX
|
XXXXXXX, XXXXX
|
0000000000
|
LSA
|
SA00138
|
XX
XXXXXXX
|
XXXXXXX, XXXXXXXX
|
0000000000
|
SA-C
|
A96160
|
4
Provider List
10/23/2008
Code | Name | National Provider Identifier | Credentials | License Number |
Last Name | ||||
XX
XXXXX
|
XXXXX, XXXXXXX
|
0000000000
|
CSA
|
CSA2617
|
XX
XXXX
|
PITA, KLEBER
|
0000000000
|
LSA
|
SA00274
|
CP
PITTY
|
PITTY, XXXXXXXX
|
0000000000
|
XXX
|
XX00000
|
XX
XXXXXXX
|
XXXXXXX, XXXXX
|
0000000000
|
LSA
|
SA00303
|
XX
XXX
|
XXX, XXXXXX
|
0000000000
|
LSA
|
SA00276
|
SR
XXXXX
|
XXXXX, XXXXX
|
0000000000
|
LSA
|
SA00090
|
XX
XXXXXX
|
XXXXXX, XXXXXX
|
0000000000
|
CSA
|
A07252
|
XX
XXXXXXXXX
|
XXXXXXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00091
|
JR
XXXXXXX
|
XXXXXXX, XXXXX
|
0000000000
|
XXX/XXX
|
XXX00000
|
XX
XXXXXXX
|
XXXXXXX, XXXXXXXX
|
0000000000
|
LSA
|
SA TEMPORARY
|
XX
XXXXXXXXX
|
XXXXXXXXX, XXXXX
|
0000000000
|
LSA
|
SA00269
|
XX
XXXXXXXX
|
XXXXXXXX, XXXXX
|
0000000000
|
CST/CFA
|
109194
|
PS
SLAVCHEV
|
XXXXXXXX, XXXXXX
|
0000000000
|
LSA
|
SA00316
|
AS
SOLOMAY
|
SOLOMAY, XXXX
|
0000000000
|
SA-C
|
A99216
|
PT01
XXXXXXX
|
XXXXXXX, XXXXX
|
0000000000
|
SA-C
|
08120
|
5
Provider List
10/23/2008
Code | Name | National Provider Identifier | Credentials | License Number |
Last Name | ||||
PT
XXXXXXXX
|
XXXXXXXX, XXXXXXXX
|
0000000000
|
LSA
|
SA00156
|
IV
XXXXX-XXXX
|
XXXXX-XXXX, XXXXXXXX
|
0000000000
|
LSA
|
SA00191
|
XX
XXXXXXXXXX
|
XXXXXXXXXX, XXXXXXX
|
0000000000
|
LSA
|
SA00249
|
XX
XXXXXX
|
XXXXXX, XXXX
|
0000000000
|
CSA
|
ABSA 08138
|
XX
XX
|
XX, XXXXX
|
0000000000
|
CSA
|
CSA2958
|
XX
XXXXXXXX
|
XXXXXXXX, XXXXX
|
0000000000
|
LSA
|
SA00056
|
BZ
XXXXX
|
XXXXX, XXXX XXXX
|
0000000000
|
LSA
|
SA00158
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6
AMENDMENT TO
AGREEMENT
BETWEEN
THREE RIVERS PROVIDER NETWORK
AND
FORT BEND SA SERVICES, INC.
This AMENDMENT to the Agreement between THREE RIVERS PROVIDER NETWORK (“TRPN”) AND (Tax Id# 00-0000000), dated 10-23-2008 (“Agreement”), is entered into and made effective as of 05-07-2010.
FOR VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby acknowledged, and in consideration of the mutual promises and mutual covenants of the parties, the parties agree that the Agreement is hereby amended as follows:
1. This Agreement is being amended due to renegotiations of the reimbursement rate in Section 1. and will now reflect the following change in rate:
a) The rate used in conjunction with this Agreement will be * discount off of Provider’s usual charge for covered services, less any applicable co-payments, co-insurance or deductibles.
2. The remaining terms and conditions of the Agreement shall remain in full force and effect unless so amended pursuant to the terms of the Agreement.
IN WITNESS WHEREOF, the parties have executed this Amendment to the Provider Service Agreement to be effective as of the Effective Date.
THREE RIVERS PROVIDER NETWORK | ||
By /s/ Xxxxx X. Xxxx, Xx. | By /s/ Xxxx Xxxxxxx | |
Signature | Signature | |
Name: /s/ Xxxxx X. Xxxx, Xx. | Name Xxxx Xxxxxxx | |
Title: COO | Title Chief Operating Officer | |
Date 5/7/2010 | Date 5/7/2010 |
*
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Portions of this document omitted pursuant to an application for an order for confidential treatment pursuant to Rule 24b-2 under the Exchange Act. Confidential portions of this document have been filed separately with the Securities and Exchange Commission.
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